PATIENT REGISTRATION FORM Please Print

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Transcription:

PATIENT REGISTRATION FORM Please Print Patient Name: Gender: Male Female Birth Age: Social Security #: Address: City, State, Zip: Home Phone #: Cell Phone #: Email: If under 18, Parent/Guardian: Parent/Guardian Social #: Relationship to Patient: Parent/Guardian Birth Would you like to receive appointment reminders via: Email Text (must select provider below) ALLTel AT&T Boost Mobile Cingular Cricket Wireless Metrocell MetroPCS Nextel Quest Sprint PCS T-Mobile US Cellular Emergency Contact: Relationship/Phone: Do you have a prescription from a physician or provider for physical therapy? Yes No If yes, who is the referring physician? How did you hear of Foothills Sports Medicine Physical Therapy? Friend/Family/Acquaintance Free Injury Screening Former Patient Foothills Employee Website/Social Media Insurance Company/Employer FAST Client Sports Club/Coach Return to Doctor Date? Verizon Virgin Mobile Location/Signage Advertisement None, Physician Referred Are you seeking Physical Therapy because of a sports injury through a school or club sport? Yes No School/Team Name: Are you seeking Physical Therapy because of a Work-Related Accident? Yes No Employer Name: Employer Address: Phone: INSURANCE INFORMATION (To be completed even if insurance card on file) Primary Insurance Insurance Co Name: Policy Holder: Policy Holder Birth Relationship to Patient: Secondary Insurance Insurance Co Name: Policy Holder: Policy Holder Birth Relationship to Patient:

PATIENT MEDICAL HISTORY FORM Patient Name: Gender: Male Female Referring Physician: Return Visit Body Part: Date of Injury: Date of Surgery: Occupation: Work Status: FT PT Unemployed Hobbies: Prior Treatment: Height: Weight: What is the nature of the current injury? Work Related Chronic/Reoccurring Fall MVA Recreational Lift or Carry Insidious Surgery What is your pain rating in the last 24 hours? 0-10 Numeric Pain Rating Scale 0 1 2 3 4 5 6 7 8 9 10 NO PAIN WORST POSSIBLE PAIN Please use the diagram provided to mark where your symptoms are currently. Symbols to Use Aching: Δ Δ Δ Burning: X X X Stabbing: / / / Numbness: = = = Pins & Needles: Radiates: My symptoms are made better by: My symptoms are made worse by: My symptoms are: Constant Intermittent Chronic New Are your work or activities of daily living limited? Yes Partial No In addition to this paperwork, you will complete a functional outcomes scale.

What is your goal for physical therapy? PATIENT MEDICAL HISTORY FORM (CONTINUED) How often do you exercise more than 20 minutes per day? 1x/wk 2x/wk 3x/wk 4x/wk 5x/wk 6x/wk 7x/wk Do you smoke? Yes No List any recent Diagnostics (Xray, MRI, CT Scan, EEG, EMG, Injections): Do you have any allergies to latex, cold, heat or medications? Yes No If yes: Are you on any medications? Please see attached list provided by the patient. Are you on any blood thinners? Yes No INR: Have you had Home Health Care or a stay with an Inpatient Facility in the last 30 days? If so, please state where: Have you been discharged? Yes No What was the date you were discharged from care? Have you fallen in the last year? Yes No If yes, how many times? Did you sustain an injury when you fell, and if so, please describe: Under what circumstances did you fall? (e.g. location, using assistive device, transferring, etc.) Past Medical History Have you recently noted any of the following? (check all that apply) Changes in Bowel or Bladder Fatigue Nausea/Vomiting Shortness of Breath Constipation Fever/Sweats/Chills Numbness/Tingling Unexplained Weight gain/loss Difficulty Swallowing Hearburn/Indigestion Pain that wakes you at night Unexplained Cough Dizziness/Lightheaded Incontinence Rapid Heart Rate/Palpitations Visual Changes Fainting Muscle Weakness Recent Onset of Headaches Prior surgeries. Please describe: Have you ever been diagnosed with any of the following? (check all that apply) Anemia Chest Pain or Angina High/Low Blood Pressure Stroke/CVA/TIA Asthma Chronic Headaches Lung Disease/COPD/ARDS TB/HIV/Hepatitis A,B,C Back Pain (Degenerative, Stenosis, Herniation) Bladder/Urinary/Kidney Disease Bone/Joint infections Congestive Heart Failure/Heart Attack Depression/Anxiety/Panic Disorders Diabetes Type I/Type II Neurological Disease (MS, Parkinson's) Osteoarthritis/Rheumatoid Arthritis Pneumonia Thyroid Condition Vascular/Circulation Problems/ Blood Clots Visual or Hearing Impairments Cancer (any) GI Disease (Liver, Ulcer, Hernia, Reflex, Gall Bladder) Seizures or Epilepsy The above information I have provided is complete, true and correct to the best of my knowledge.

PATIENT INFORMATION AND CONSENT FORM CONSENT FOR CARE AND TREATMENT: I hereby agree and give my consent to Foothills Sports Medicine Physical Therapy to furnish appropriate rehabilitative care and treatment, as considered necessary and in the best interest in order to attend to the physical condition. I understand that the benefits and risks to all interventions will be explained and that the patient holds the final judgment in such matters. MEMBER DIRECT PAYMENT NOTIFICATION: Arizona state constitution permits you to pay a healthcare provider for health care services directly. If you have any active health insurance coverage, please review the provider s policies regarding payment before you make any arrangements to pay directly. AUTHORIZATION TO PAY: I hereby authorize insurance payment directly to Foothills Sports Medicine Physical Therapy, Billing Department, 15410 S. Mountain Pkwy. Suite 112, Phoenix, AZ 85044 for medical services rendered. I understand that I am financially responsible for the charges not covered by my insurance. In the event of default, I promise to pay collection costs and reasonable fees as may be required to obtain collection of this account. ATTENDANCE AGREEMENT: Due to the nature of physical therapy, your progress and full recovery are dependent on both our experienced physical therapists, and your active participation and commitment to your appointments. If you need to cancel your appointment, please contact Foothills Sports Medicine at least one day prior to your appointment. If you call to cancel your appointment on the same day as your appointment or if you do not show, a $25.00 cancellation fee will be assessed. WORKERS COMPENSATION PATIENTS: We are required to inform your Workers Compensation Adjuster and/or Rehabilitation Manager of all missed or canceled appointments. It is also required that all missed visits be rescheduled. AUTHORIZATION TO COMMUNICATE ELECTRONICALLY: I understand that authorized personnel (including my physical therapist) from Foothills Sports Medicine Physical Therapy may communicate with me regarding scheduling/ appointments, the treatment provided, home exercise programs, and educational/informative content as it relates to my condition. I understand that my protected health information (PHI) will not be communicated electronically. I understand that I have the opportunity to opt-out of future communications at any time using the unsubscribe option on any communication via text or email. By my signature below, I certify that I have read, understand, and fully agree to each of the statements in this document. Printed Name:

NOTICE OF PATIENT INFORMATION PRACTICES This notice describes how medical information about you may be used or disclosed and how you can get access to information. Please review it carefully. FOOTHILLS SPORTS MEDICINE PHYSICAL THERAPY S LEGAL DUTY Foothills Sports Medicine Physical Therapy is required by law to protect the privacy of your personal health information, provide this notice about our information practices, and follow these practices that are described herein. USES AND DISCLOSURES OF HEALTH INFORMATION Foothills Sports Medicine Physical Therapy uses your personal health information primarily for treatment; obtaining payment of treatment; conducting internal administrative activities, and evaluating the quality of care that we provide. For example, Foothills Sports Medicine Physical Therapy may use your personal health information to contact you to provide appointment reminders, or information about treatment alternatives or other health related benefits that could be of interest to you. Foothills Sports Medicine Physical Therapy may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law. In any other situation, Foothills Sports Medicine Physical Therapy s policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization through a written statement to stop future disclosures at any time. Foothills Sports Medicine Physical Therapy may change its policy at any time. When changes are made, a new Notice of Information Practices will be posted in the clinic and will be provided to you on your next visit. You may also request an updated copy of our Notice of Information Practices at any time. PATIENT S INDIVIDUAL RIGHTS You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate information or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes. You may also request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. Foothills Sports Medicine Physical Therapy will consider all such requests on a case by case basis, but the practice is not legally required to accept them. CONCERNS AND COMPLAINTS If you are concerned that Foothills Sports Medicine Physical Therapy may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact the person(s) listed below. You will not be retaliated against for filing a complaint. Barry Holland, Compliance Officer Department of Health and Human Services 15410 South Mountain Parkway, Suite 107 Mail, fax, email, or OCR Complaint Portal Phoenix, AZ 85044 www.hhs.gov/ocr/hipaa/ 480.689.5510

PATIENT INFORMATION ACKNOWLEDGEMENT FORM I have read and fully understand Foothills Sports Medicine Physical Therapy s Notice of Information Practices. I understand that Foothills Sports Medicine Physical Therapy may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment, and administrative operations if I notify the practice. I also understand that Foothills Sports Medicine Physical Therapy will consider requests for restriction on a case by case basis. I hereby consent to the use and disclosure of my personal health information for purposes as noted in Foothills Sports Medicine Physical Therapy s Notice of Information Practices. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time. Printed Name: DESIGNATED INDIVIDUALS AUTHORIZATION FORM I hereby authorize one or all of the designated parties listed below to request and receive the release of any protected health information regarding my treatment, payment or administrative operations related to treatment and payment. I understand that the identity of designated parties must be verified before the release of any information. Authorized Designees: Printed Name:

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